Online Patient Forms

Patient Registration and Medical History Form

Thank you for using our secure online forms. Please fill out as much information as you can. When you are finished be sure to hit the submit button at the bottom of the form. If you have any questions, please call us at (808) 949-2662. We can always change the data in the office if you are unsure about what to enter in any of the fields.

First Name

*This field is required

M.I.

Last Name

*This field is required

Nickname

Birth Sex

Male Female

Address

Apt/Suite #

City

State

Zip Code

Cell Phone

*This field is required

Home Phone

Other Phone

Preferred Contact Method

Occupation

Employment Status

Employed

Full-time Student

Part-time Student

Employer/School Name

Work Phone

Birthday

Pronoun

Gender Identity

Marital Status

Misc/Guardian

Who may we thank for referring you to our office?

Billing information

Is The Billing Address Different? Yes

If yes, please provide the billing address information below

Title

First

Last

Middle

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Please choose from the menu options or select the option to type in your own text. Thank you!

Patient Ocular History

What is the reason for todays exam. List any vision symptoms you are having:

     • blurred vision, headaches, eyestrain, double vision, or losing your place when reading

     • itching, burning, redness, pain, sensitivity to light, watering, crusting or mucus discharge

     • seeing rainbows around white lights at night, flashes of light or dark spots/squiggles/webs

When was your last eye exam?

Check the box for any conditions that apply:

You Mom Dad Sib Describe (type, when diagnosed, which eye(s), treatment,etc)

Glaucoma

Macular Degeneration

Retinal problems

Cataracts

Lazy Eye/Eye Turn

Please list any EYE medications you are taking.

Please list any OVER THE COUNTER eye drops you are using.

Please list any EYE surgeries you have had.

Do you currently wear eyeglasses? If "YES", How long have you had the current prescription?

Contact Lens Wearers Only

Do you currently wear contact lenses? If "YES" , how long have you worn them?

How many hours a day do you wear your contact lenses?

How frequently do you replace your contact lenses ? (every 2 weeks, month, year, etc.)

What contact lens solutions do you use?

Medical History

What is the name of your primary care physician?

Check the box for any conditions that apply:

You Mom Dad Sib Describe (type, when were you diagnosed, etc)

Hypertension

Thyroid

Cardiovascular

Cancer

Diabetes

Please list any MEDICATIONS you are taking.

Please list any allergies to medications.

List any surgeries you have had (cataract, tonsillectomy, appendectomy, etc):

Are you pregnant or nursing?

Do you smoke?

Review of Systems

GENERAL HEALTH: Fever, weight loss, weight gain, fatigue? NO

SKIN: Growths, rashes, acne, rosacea, eczema, skin cancer? NO

EAR, NOSE THROAT: Allergies, sinus, cough, dry mouth/ throat? NO

RESPIRATORY: Asthma, bronchitis, emphysema, COPD? NO

MUSCLES, BONES, JOINTS: Arthritis, joint pain, head or neck injury? NO

PSYCHIATRIC: Depression, anxiety, insomnia? NO

ENDOCRINE: Grave's disease, hyperthyroid, diabetes, gout? NO

BLOOD /LYMPH :Anemia, cholesterol, bleeding problems? NO

NEUROLOGICAL: Headaches, migraines, seizures? NO

ALLERGIC / IMMUNOLOGIC : Allergies, rheumatoid arthritis, AIDS, Lupus? NO

GENITAL, KIDNEY, BLADDER: Kidney stones, frequent urination, impotence. NO

GASTROINTESTINAL: Diarrhea, constipation, ulcer, reflux. NO

CARDIOVASCULAR: High blood pressure, heart surgery, vascular disease. NO

	You	Mom	Dad	Sib	Describe (type, when diagnosed, which eye(s), treatment,etc)
Glaucoma
Macular Degeneration
Retinal problems
Cataracts
Lazy Eye/Eye Turn

	You	Mom	Dad	Sib	Describe (type, when were you diagnosed, etc)
Hypertension
Thyroid
Cardiovascular
Cancer
Diabetes